Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators
Does Point-of-Care Ultrasonography Improve Clinical Outcomes in Emergency Department Patients With Undifferentiated Hypotension? An International Randomized Controlled Trial From the SHoC-ED Investigators
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DOI：
10.1016/j.annemergmed.2018.04.002
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发表时间：
2018-10-01
影响因子：
6.2
通讯作者：
Lewis, David A.
中科院分区：
文献类型：
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作者：
Atkinson, Paul R.;Milne, James;Lewis, David A.
研究目的：床旁超声检查方案通常用于急诊科 (ED) 未分化低血压患者的初始治疗。几乎没有公开的证据表明任何死亡率方面的益处。我们比较了床旁超声检查方案与不使用床旁超声检查的标准护理对生存和临床结果的影响。 方法：这项国际、多中心、随机对照试验从北美和南非的 6 个中心招募，纳入了选定的低血压患者（收缩压 < 100 mm Hg 或休克指数 > 1），随机接受早期床旁超声检查加标准护理与不使用床旁超声检查的标准护理。在 0 和 60 分钟时记录诊断。主要结局指标是存活 30 天或出院。次要结局指标包括初始治疗和调查、入院和住院时间。结果：273 名患者中的 270 名患者完成了随访。超过一半的患者最常见的诊断是隐匿性脓毒症。我们发现各组之间的主要生存结局没有显着差异（床旁超声检查组 136 名患者中的 104 名患者与标准护理组 134 名患者中的 102 名患者；差异 0.35%；95% 二项置信区间 [CI] -10.2% 至 11.0%）、北美生存率（床旁超声检查组 89 名患者中的 76 名患者与标准护理组 88 名患者中的 72 名患者；差异3.6%；CI -8.1% 至 15.3%），以及南非的生存率（护理点超声检查组 47 名患者中的 28 名与标准护理组 46 名患者中的 30 名；差异 5.6%；CI -15.2% 至 26.0%）。计算机断层扫描 (CT) 扫描率、正性肌力药或静脉输液的使用率以及 ICU 或总住院时间没有显着差异。 结论：据我们所知，这是第一个在未分化低血压 ED 患者中比较床旁超声检查与不使用床旁超声检查的标准护理的随机对照试验。我们没有发现对生存、住院时间、CT 扫描率、正性肌力药物的使用或输液有任何益处。在标准护理中添加即时超声检查方案可能不会转化为该组患者的生存获益。
Study objective: Point-of-care ultrasonography protocols are commonly used in the initial management of patients with undifferentiated hypotension in the emergency department (ED). There is little published evidence for any mortality benefit. We compare the effect of a point-of-care ultrasonography protocol versus standard care without point-of-care ultrasonography for survival and clinical outcomes.Methods: This international, multicenter, randomized controlled trial recruited from 6 centers in North America and South Africa and included selected hypotensive patients (systolic blood pressure < 100 mm Hg or shock index > 1) randomized to early point-of-care ultrasonography plus standard care versus standard care without point-of-care ultrasonography. Diagnoses were recorded at 0 and 60 minutes. The primary outcome measure was survival to 30 days or hospital discharge. Secondary outcome measures included initial treatment and investigations, admissions, and length of stay.Results: Follow-up was completed for 270 of 273 patients. The most common diagnosis in more than half the patients was occult sepsis. We found no important differences between groups for the primary outcome of survival (point-of-care ultrasonography group 104 of 136 patients versus standard care 102 of 134 patients; difference 0.35%; 95% binomial confidence interval [CI] -10.2% to 11.0%), survival in North America (point-of-care ultrasonography group 76 of 89 patients versus standard care 72 of 88 patients; difference 3.6%; CI -8.1% to 15.3%), and survival in South Africa (point-of-care ultrasonography group 28 of 47 patients versus standard care 30 of 46 patients; difference 5.6%; CI -15.2% to 26.0%). There were no important differences in rates of computed tomography (CT) scanning, inotrope or intravenous fluid use, and ICU or total length of stay.Conclusion: To our knowledge, this is the first randomized controlled trial to compare point-of-care ultrasonography to standard care without point-of-care ultrasonography in undifferentiated hypotensive ED patients. We did not find any benefits for survival, length of stay, rates of CT scanning, inotrope use, or fluid administration. The addition of a point-of-care ultrasonography protocol to standard care may not translate into a survival benefit in this group.